Nurse-midwifery education has existed in the United States since 1925.1–3 Originally, nurse-midwifery was an answer to what was called the “midwife problem” in the early 1900s. The indigenous, immigrant, and African American granny midwives practicing at that time lacked national organization, a national journal for communication, access to the health care system, and legal recognition. This left them vulnerable to attacks against their profession and the work they did.2 The history of nurse-midwifery education is interwoven with the history of parallel developments and recurrent issues within the profession. Parallel developments include 1) the definitions of a nurse-midwife and nurse-midwifery practice, 2) identification of the content of nurse-midwifery practice and therefore curriculum, 3) the location of education programs, 4) the basis for legal recognition, and 5) the evolution and securing of the credentialing mechanisms of accreditation for education programs and certification for practitioners. The most prevalent recurring issue has been the relationship of nurse-midwifery to nursing. To understand the evolution of nurse-midwifery education in the United States, one has to understand this relationship and the influence nursing has had on nurse-midwifery. This influence is evidenced in the struggle over defining nurse-midwifery and nurse-midwifery practice; the continuing debate over whether nurse-midwifery is a clinical specialty of nursing; and the ongoing effort it has taken to preserve our credentialing mechanisms separate from nursing, maintain our position on degree requirements for entry to practice, and persevere in our commitment to diverse academic locations for nurse-midwifery education programs. Nurse-midwifery has grappled with its origins. The autonomy that midwives had was sacrificed for credibility and access to the health care system. Nurse-midwifery was started against rancorous opposition. The profession was allowed to come into being only attached to nursing and under the auspices of medical supervision and control. It is necessary to understand the context within which nurse-midwifery developed to understand the compromises made at that time, which still affect the profession today.4 It is clear that the early promoters of nurse-midwifery, while understanding that nursing and midwifery were 2 different professions, also understood that to survive and thrive, nurse-midwifery had to make itself acceptable to the mainstream health care system (i.e., nursing and medicine). A joint committee of the National Organization of Public Health Nurses (NOPHN) and the National League for Nursing Education (NLNE) in the mid-1920s entitled “The NOPHN/NLNE Committee on Post Graduate Courses in Midwifery for Nurses” demonstrates the serious interest in midwifery education for nurses held by national nursing organizations during the early 20th century.5 The original idea was that nurses with a public health background would study midwifery to become nurse-midwives and that midwifery would be a specialty within nursing. Calling nurse-midwifery a clinical specialty in nursing retained health care system access and acceptance at a time when the word “midwife” conjured up, albeit unfairly, derogatory images. Physicians wanted to call nurse-midwives “obstetric assistants” and promoted this idea into the 1960s.6 The leaders in public health nursing were supportive of the early development of nurse-midwifery. The Nurse-Midwifery Section of the NOPHN, 1944 to 1952, was the first successful national organization of nurse-midwives. Among the many activities and accomplishments of the Section during its existence was the development of a philosophy and standards for nurse-midwifery education.5, p. 97 The Section also wrote a definition of a nurse-midwife as a professional educated in “the disciplines of medical obstetrics and midwifery.” However, by the time “NOPHN dissolved as an organization in 1952, the section had yet to determine if there was agreement in the specific content of existing education programs and the place of a nurse-midwifery course in the ‘scheme of graduate nursing education.’”5, p. 98 The Committee on Organization (the Committee), which led to the formation of the American College of Nurse-Midwifery, was established in 1954 and chaired by Sr. Theophane Shoemaker. The Committee stated that one of the reasons for organizing was to “set standards for education.”7 In addition to all the other issues and tasks involved in considering the start of a national organization, the Committee “proceeded to formulate some tentative educational standards for the nurse-midwifery schools.” These included eligibility requirements for admission, basic faculty requirements, and a rudimentary curriculum outline. The verbiage used in these tentative standards made it clear that nurse-midwifery education was to take place in or be affiliated with a university.8 The Committee also wrote a definition that said, “The nurse-midwife combines the knowledge and skills of professional nursing and midwifery, enabling her, in addition to the usual nursing functions, to assume full responsibility for the education and care of mothers throughout the maternity cycle so long as progress is normal….”9 However, the first definition approved by the membership of the American College of Nurse-Midwifery in 1962 was substantively different. Carrington and Varney Burst detail in their article on the history of the Division of Accreditation in this issue of the Journal the influences of nursing and the National League for Nursing that brought about this definition that stated that “Nurse-Midwifery is an extension of nursing practice into the area of management of care of mothers and babies throughout the maternity cycle so long as progress meets criteria accepted as normal.” Management of care or full responsibility for this care was no longer identifiably defined as midwifery. There have been 7 nurse-midwifery education workshops (1958, 1967, 1973, 1976, 1977, 1980, and 1992).10–16 Both the 1958 and 1967 Work Conferences on Nurse-Midwifery Education were predicated on the premise that “nurse-midwifery is a clinical nursing specialty.”10,11 However, by 1967, many nurses felt that nurse-midwives functioned outside of nursing. Nurse-midwives at the 1967 Work Conference on Nurse-Midwifery Education emphasized the need to have professional nursing understand and accept the concept of nurse-midwives extending practice into the management of care by nurses and that “nurse-midwives must find more effective means of interpreting their place within nursing to other nurses.”11, p. 45 The definition of a nurse-midwife was contentious until the debate on whether midwifery was nursing was put to rest with the definition approved by 82% of the 50% of the membership voting in 1978.17 This definition stated that “A Certified Nurse-Midwife (CNM) is an individual educated in the two disciplines of nursing and midwifery, who possesses evidence of certification according to the requirements of the American College of Nurse-Midwives.” The 1978 definition has remained unchanged to this time. The clarity of recognizing the 2 disciplines of nursing and midwifery, and therefore acknowledging each discipline as separate from the other, enabled ACNM a decade and a half later to institute direct entry midwifery education. However, this definition did not end the debate on whether nurse-midwifery was a clinical specialty of nursing, nor did it address the academic setting within which a nurse-midwifery education program would reside. The continuing debate on whether nurse-midwifery is a clinical specialty of nursing has now taken on the language of “advanced nurse practice.” Part of the impetus for this continuing debate is based on 2 facts. First, despite the recommendation of the ACNM Legislation Committee in 1974 (approved by the ACNM Board of Directors) that nurse-midwives seek separate statutory recognition,18 the legal recognition for nurse-midwifery practice in the majority of states is within statutes governing advanced nurse practice. Over the past 2 decades, some of these state statutes have required a master's degree for licensure as an advanced practice nurse. This led to an ACNM statement opposing mandatory degree requirements for nurse-midwives, first in 1985,19 again in 1992,20 and then again in 1997 and 1998.21 However, the discussion of the academic level necessary for nurse-midwifery education was intensified. Currently, the discussion within nursing is of the practice doctorate in nursing (e.g., DNP or DrNP),22 which again will have ramifications for nurse-midwives and nurse-midwifery education. Second, the majority of nurse-midwifery education programs are within Schools of Nursing. Of the 45 nurse-midwifery and midwifery education programs listed in the 2004 ACNM Membership Directory, 35 programs are in Schools of Nursing and 10 are in other academic units: 4 in Schools of Medicine, 2 in Schools of Public Health, 2 in Schools of Health-Related Professions, 1 in a Graduate School, and 1 in its own institution. The early nurse-midwifery education programs were proprietary, and thus were all certificate programs unaffiliated with a university (Figures 1 and 2). The first university affiliation was between The Flint-Goodrich School of Nurse-Midwifery and Dillard University in New Orleans, but the program, a certificate program, only existed for 1 year, from 1942 to 1943.23 Catholic University affiliated with Catholic Maternity Institute (CMI) in 1947. This remained the only university affiliation until the mid-1950s when Columbia University (1955), Johns Hopkins University (1956), and Yale University (1956) started nurse-midwifery education programs, and the Maternity Center Association (MCA) nurse-midwifery program affiliated with the State University of New York, Downstate Medical Center in Brooklyn in 1958.2,3 Three of these programs (CMI, Johns Hopkins, and MCA) were certificate programs and 3 were master's degree programs (Catholic University, Columbia, and Yale10,24 (Figure 3). The other 4 programs in existence between 1930 and the 1950s were all certificate programs: The Frontier Graduate School of Midwifery started in 1939 (Figure 4), the Tuskegee School of Nurse-Midwifery in existence from 1941 to 1946, the Flint-Goodrich School of Nurse-Midwifery from 1942 to 1943, and the School of Nurse-Midwifery of the Puerto Rico Department of Health at Hato Rey in existence from 1954 to 1960.2,3,10,23,25,26 This meant that while nurse-midwifery educators were talking about situating nurse-midwifery education within or affiliated with university settings, the reality was that more than half of the existing programs were neither. In addition, of the 10 programs, 4 were proprietary or government sponsored, 1 was in transition from a proprietary school to being within a College of Health-Related Professions, 1 was in a School of Public Health, and 4 were in Schools of Nursing. Lobenstine School of Midwifery, New York City, established 1932. Margaret Thomas, SNM, pictured. Photo courtesy of Maternity Center Association. Rose McNaught, RN, SCM, teaching student nurse-midwives at Lobenstine/Maternity Center Association School of Midwifery, circa 1930s. Photo courtesy of Maternity Center Association. Ernestine Wiedenbach, CNM, standing, with nurse-midwifery students, class of 1959, at Yale University School of Nursing. Included are Armentia Jarrett, SNM, on left next to Ernestine Wiedenbach and Elizabeth Sharp, SNM, on far right. Photo courtesy of Maternity Center Association. Nurse-midwifery class at Frontier Graduate School of Midwifery, circa 1950. Photo courtesy of Frontier Nursing Service, Hyden, KY. LOBENSTINE The Only School for Nurse-Midwives in the United States The participants in the 1958 Work Conference on Nurse-Midwifery Education declared that “Education for nurse-midwives can best be provided in a university setting” and envisioned curriculum goals at a graduate school level, with a program leading to a master's degree. “The conference group realized, however, that the non-degree program is a part of the educational and service picture today, and will continue to be for some time to come.”10, p. 44 Nonetheless, the initial ACNM Division of Approval Criteria for Evaluation of Educational Programs in Nurse-Midwifery in 1962 included the criterion that “The educational program in nurse-midwifery is established within or affiliated with a college or university.” Five more nurse-midwifery education programs started during the 1960s, 4 of which were within institutions of higher education: University of Puerto Rico at Caparra Heights, New York Medical College, University of Utah, and University of Mississippi. Two of these were in Schools of Nursing, 1 was in a School of Public Health, and 1 was in a School of Medicine. The fifth program was in Ponce District Hospital in Puerto Rico.2 The participants in the 1967 Work Conference on Nurse-Midwifery Education recommended “That by 1977 all schools preparing nurse-midwives, and all new educational programs developed from that date on, be organized within accredited institutions of higher education” and “That all professional nurse-midwifery programs be built upon the foundation of the baccalaureate degree in nursing.”11 The ACNM Executive Board charged the Education Committee with review and revising, if necessary, this latter recommendation. The Education Committee completed their charge and recommended that the statement be changed to read “That all nurse-midwifery programs be on the baccalaureate or higher degree level.”27 Subsequently, the Education Committee became part of the Education and Clinical Practice Coordinating Committee, which coordinated the work of the Clinical Practice, Approval, and Testing Committees from 1967 to 1975.28 The Education and Clinical Practice Coordinating Committee prepared a 1971 document entitled Approved Patterns of Nurse-Midwifery Education, which not only listed the existing certificate and master's degree levels of educational preparation as approved patterns of nurse-midwifery education, but also recommended the development of baccalaureate programs.27 By 1998, the Division of Accreditation criteria for the preaccreditation and accreditation of nurse-midwifery and midwifery education programs stated that a certificate program “is into a program of professional that a baccalaureate degree upon or which no than a baccalaureate The certificate programs this criterion by a baccalaureate degree upon Of the 45 education programs listed in the 2004 ACNM Membership Directory, 4 are certificate programs, 3 of which have a master's This the issue of mandatory degree requirements for licensure as an advanced practice nurse no longer for state requirements are so the degree required for licensure must be in nursing. The Education Committee was as a separate Committee to to of the on during a joint held in and has a in the development of nurse-midwifery and midwifery education. include the development of as in Nurse-Midwifery, first in 1978 and and for Educational Programs first in to The for Educational Programs listed 4 programs midwifery programs, programs, programs not in a university and with criteria for each program in the of students, and review and were to the Division of Accreditation and to the Nurse-Midwifery Education for The Education Committee and the Division of Accreditation over these most of the in a discussion by the Nurse-Midwifery Education the Education Committee again of the to to of this group and for their about the criteria for midwifery The was a of the only on a direct entry midwifery program with criteria to be in addition to Division of Accreditation the time, in a of and by the for Education, the Board of of the American College of Nurse-Midwives stated that “The ACNM will the Division of the of professional midwifery educational by ACNM and by the first ACNM Division of Accreditation accredited direct entry midwifery program are in in the Journal of The work of the Division of Accreditation in this is in the article by Carrington and Varney Burst in this issue of the The first 2 nurse-midwifery education workshops in 1958 and 1967 on the need of nurse-midwifery education to an accreditation whether or not to and the of nurse-midwifery more to the of maternity from a and and to nurses and than to the practice of nurse-midwifery. of the early and work from these workshops became criteria in the ACNM later A recommendation from the led to the preaccreditation The was a nurse-midwifery as the to education issues were as on the of service and The 1977 and recommended in the criteria used by the Division of The need for was the and then became a issue the first document was in The development of a was recurring that when programs developed mechanisms the of the curriculum in the recurring included discussion of different educational first to nurse-midwifery different levels of academic and then about different to midwifery. The was an extension of the of the Nurse-Midwifery Education to include faculty and was held to address 2 1) a nursing background necessary for nurse-midwifery and 2) is responsibility in to and The participants into to address 3 and make 1) or in midwifery in this 2) is the educational preparation for and 3) are the and preparation and were in the early the of nurse-midwifery practice the of to clinical practice in the curriculum (Figure preparation became of an programs, there were still programs that retained a of at 1 of the However, preparation for teaching became a issue as education programs on clinical in practice In the Division of Accreditation a criterion during the that required evidence of preparation for all who were involved in teaching CNM, of the Nurse-Midwifery Education at the University of on right. on with the first in as a student Photo courtesy of The on Nurse-Midwifery Education, when with the early nurse-midwifery education demonstrates far the profession had The had of the of nurse-midwifery care and the nurse-midwifery can make within the health care system. In addition, there was no longer a need to to the of educational curriculum, curriculum, and the the issues of public health and the of nurse-midwifery to the public the auspices of and state and and of to this The were from a position of of a of educational and thus on organizing and to nurse-midwifery to an of the of care to educational workshops have been held since the of the ACNM Certified and the ACNM Division of Accreditation preaccreditation and accreditation of midwifery programs. Certified the and take the certification as Certified it is that they will on in the of care to from and that the from the education are to the nurse-midwifery education program have been to the development of nurse-midwifery education. have in on the Education Committee, the Testing Committee the Division of and now the ACNM and in the of the Division of Board of and have been participants in all of the work and workshops on nurse-midwifery education. of these activities have been issue the In the faculty of the nurse-midwifery education program in the Department of and at the University of Medical Center held the of 2 by the Health of the Department of Health, Education, and on the curriculum they had developed and The first the faculty and student and certification to all the nurse-midwifery education program in the The was a for who wanted to this educational in their own programs. also of this was a time for (e.g., faculty student and with The a need for more of the Nurse-Midwifery Education started in and for many was a It also provided for new and issues into the and time was to with the ACNM of the Division of of the and a of the Division of of program By the the were a during the of in the Nurse-Midwifery Education and became the of Midwifery Education to the development of nurse-midwifery education programs were the of nurse-midwifery clinical The ACNM on to the for Nurse-Midwives in the United the necessary between these 2 of the profession. A ACNM document stated that established nurse-midwifery service with or for for student a new basic nurse-midwifery educational In the was the and the Education at the time and place in the with at half a to a joint to of the of in the nurse-midwifery Five parallel and of development in the and which the practice and curriculum of nurse-midwifery. was the early work of the ACNM Testing Committee during the 1960s, which was to what of and were to be with this effort the continuing discussion of curriculum during the 1967, and education was the development of the nurse-midwifery curriculum at the University of Medical Center in which and clinical and the first document in the of the first in nurse-midwifery in was the next in the evolution of nurse-midwifery education. has a history in education with study in the to in which the and are by time, or of in nurse-midwifery were developed of state that or were not clear about the legal of the practice of nurse-midwifery. University in started a nurse-midwifery program in but had to their of state for clinical did not have nurse-midwifery licensure until The of clarity in state was part of the that Yale University their nurse-midwifery of state for from the start of their program in until the programs to some of a Two of access to nurse-midwifery education were now of programs to accept of of to to the in which programs was as a many with each for the next to In 1976, envisioned a within the Nurse-Midwifery Education of the University of Medical Center for for a of their education and from the National for the of were and a to it the University of the study and their and to the Medical University of to on their initial had been by 3 different in and that nurse-midwives in their own there were no nurse-midwifery education a of was held in during the of a for a to the National of It was approved but not In to 1980, University in had a affiliation with in for 4 who had their educational at A University faculty and between and to the A effort place when Nurse-Midwifery Center in the College of and of New to on an education The first class was in to A from the program was that the was to the program, and the had some of their with their in New In 1980, The Health was developed at University, to midwifery to and nurse in in of The remained in their in their practice to for 2 2 but all clinical was in their A in which in the area to the place of to clinical and was A system was developed to in their programs of study as they the clinical and requirements at their own in nurse-midwifery education a with the development of the Nurse-Midwifery Education which started in of the of the history of the of the program, and developments in in education is in the article by and in this issue of the the first time, the from in for nurse-midwifery education were on a and the program was to have a on the of practicing nurse-midwives. In addition, had now far and its 2 the nurse-midwifery education programs at the State University of New York at and the Institute of Midwifery, and Health, made the of and that led nurse-midwifery education into the new not only the of the American College of but also the of nurse-midwifery education. The history of nurse-midwifery education is and (Figure It the history of the profession and its not only in but also in understanding of our Education is the of the and with our Journal for communication, our national organization to our individual and the credentialing mechanisms of and licensure that and have the basic not only for but for our of student nurse-midwives at Columbia University, circa Photo from the of Varney CNM, ACNM goals for the profession First, and will be practicing in as the of health and maternity care and of all and will be in the public of the health care system CNM, ACNM The Board of has approved a that will our in the national This to and will our and in the practice in detail than have also to at the organization in to a system that is and as as of our are our with the for the ACNM and will on issues of that have been by our